The Care Quality Commission
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Wye Valley NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

12 Nov to 19 dec

During an inspection of Community health services for adults

Our rating of this service stayed the same. We rated it as good because:

  • The service had staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients. They managed medicine prescribing well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

  • Records were not clear and easily available to all staff providing care. It was difficult to find the most recent information, including risk assessments, and not all patient documentation had been completed fully, updated or was missing. Not all staff had full access to the patient notes system and could only see their departments notes.
  • Staff felt that due to staff shortages, they did not have the time needed to complete a full holistic assessment or visit. Capacity also impacted in their ability to fully complete patient documentation.
  • The service had not met its target to have 90% of staff trained in basic life support.

12 Nov to 19 dec

During a routine inspection

Our rating of the trust stayed the same. We rated it as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement and caring as good.
  • We rated seven of the trust’s 13 services as good and five as requires improvement and one as inadequate. In rating the trust, we took into account the current ratings of the five services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • During this inspection, we did not inspect services for children and young people, acute end of life care and outpatients. We also did not inspect, community health services for children and young people or community dental services. The ratings we published following the previous inspections are part of the overall rating awarded to the trust this time.

12 Nov to 19 dec

During an inspection of Community health inpatient services

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not have enough staff to care for patients and keep them safe. Staff reported being overstretched and unable to complete the necessary recording of all the care interventions and assessments they completed. Staff assessed risks to patients and acted on them but did not always kept good care records to evidence this. The service did not routinely implement all infection prevention control measures, such as staff remaining “bare below the elbow”. The service provided mandatory training in key skills to all staff but did not make sure everyone completed it.
  • Staff did not always store patient records securely and did not always update individual patient records in a timely manner. Some staff told us this was because there was not enough time for them to do so.
  • There was no clinical audit programme to benchmark and monitor the effectiveness of the service. There were limited measures to monitor and evaluate patient outcomes.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

12 Nov to 19 dec

During an inspection of Community end of life care

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However

  • A syringe driver policy was in place and available to all staff via the intranet. However, at Bromyard Community Hospital and the Hereford District Nursing base staff were not sure where to access an up to date policy and were only able to show us an out of date policy.

4 June to 11 July 2018

During a routine inspection

Our rating of the trust stayed the same. We rated it as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement and caring as good.
  • We rated seven of the trust’s 13 services as good and six as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • During this inspection, we did not inspect critical care or acute end of life care services. We also did not inspect community health services for adults, community health services for children, young people or community dental services. The ratings we published following the previous inspections are part of the overall rating awarded to the trust this time.

4 June to 11 July 2018

During an inspection of Community health inpatient services

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service provided mandatory training in key skills to all staff but did not make sure that everyone completed it. Mandatory training compliance rates were below the trust target. Registered nursing staff and health care assistant staff at all community hospital sites did not meet the trust target of 90% compliance with mandatory training.
  • The service did not always control infection risk well. Staff did not always keep themselves, equipment and the premises clean at all times across all sites. They sometimes used control measures to prevent the spread of infection.
  • The service had suitable premises to meet patient’s needs; however, the environment was not always kept secure as doors were found to be unlocked at times.
  • Equipment had not always been regularly tested for safety in accordance with policy. The asset register for equipment and compliance log was kept by Hereford County Hospital but we saw that there was no local oversight of this process. We were not assured that processes were in place for monitoring equipment compliance locally or that there was a robust process for ensuring the equipment at the community hospitals was safe to use.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Although actual staffing levels generally met planned staffing levels, we saw that there were delays in providing patient care at times during the inspection.
  • Medicines were not consistently prescribed, given or recorded according to best practice. Patients did not always receive the right medication at the right dose at the right time. Medication was not always safely stored and some medication was found to be expired.
  • Staff were not always competent for their roles. Managers did not consistently appraise staffs’ work performance through an annual performance review process. Supervision meetings were not held regularly between managers and staff in order to provide support and monitor the effectiveness of staff.
  • The service did not demonstrate that it consistently provided care and treatment based on national guidance or evidence of its effectiveness. Managers did not have policies or processes in place to ensure that staff followed guidance and best practise.
  • Effectiveness of care and treatment was not always monitored, although nursing teams used clinical audit findings to improve practise. Local results were not routinely compared with those of other services to learn from them. Some limited outcome measures were used by therapists but there was no audit of patient outcomes.
  • The service did not always take account of patients’ individual needs.
  • Arrangements to admit, treat and discharge patients were not always in line with good practice; routine medical and therapy services were not readily available over the weekends.
  • The service treated concerns and complaints seriously, and investigated them, however, they did not always respond to complaints within the trust target timeline. Lessons learned from the results of complaint investigations, were not shared with all staff.
  • The trust did not routinely collect, analyse, manage or use information well to support all its activities. Secure electronic systems with security safeguards were not in place for record keeping or sharing transfer of care information.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Although not all staff had training on how to recognise and report abuse most staff had knowledge of the safeguarding policy and knew how to apply it.
  • Risks to people who used services were assessed, and their safety was monitored and maintained. We reviewed 15 sets of records which demonstrated that patients had received a holistic assessment which included using national risk assessment tools in, for example, nutrition, fall risks, skin integrity and pressure areas.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The information was used to improve the service.
  • The service generally managed patient safety incidents appropriately. Most staff recognised incidents and reported them. Managers investigated incidents, although lessons learned were not always shared with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff worked together as a team to benefit patients. Doctors, nurses, therapists and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

4 June to 11 July 2018

During an inspection of Community end of life care

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Lessons were not always learned and improvements made when things go wrong. We were told that incidents in the community relating to prescribing anticipatory medicines had been addressed but were not routinely reported via the electronic reporting system. This meant that trends and opportunities for learning were not necessarily identified.
  • Comprehensive risk assessments were carried out on patients at the end of life in community hospitals and in their own homes. However, we saw one example where the action and learning from an incident relating to a pressure ulcer did not address all of the factors relating to the potential cause such as staffing and workload concerns.
  • Patients were not always identified who may need extra support. For example, patients in the last 12 months of their lives were not always identified, particularly when they had non-malignant conditions. This meant they may not receive the range of support and services available to them.
  • The trust did not have an end of life care strategy in place and there was no trust wide end of life care forum in place. The Trust were signed up to a Clinical Commissioning Group end of life strategy alongside other stakeholders and were part of a county wide end of life care forum. The county wide end of life care forum did not meet regularly and staff were unclear what the focus of the meetings were between end of life care and mortality oversight. Objectives identified by the specialist palliative care team had not been agreed at trust board level and there was no clear plan for how the objectives would be achieved.
  • There were arrangements in place for managing risks relating to end of life care services. However, only one risk had been identified on the risk register relating to the loss of an end of life care facilitator post in November 2017, despite additional risks being identified.
  • Systems that manage information about patients who use services did not always support staff, carers and partner agencies to deliver safe care and treatment. A community nurse scheduler was described as ‘not fit for purpose’ and at the time of our inspection had temporarily failed, leading to one end of life care patient not being seen as planned.
  • Staff did not always have appropriate training to meet their learning needs. Nursing staff working in the community hospitals had not all had update training in the use of syringe drivers and the verification of death.
  • The assessment of mental capacity relevant to discussions around ‘do not attempt cardiopulmonary resuscitation’ was not recorded in five out of seven cases where patients were not involved in discussions or decisions due to an identified lack of mental capacity.
  • The services provided generally reflected the needs of the population served. However, the specialist palliative care team had identified a need to increase their support for patients with non-malignant conditions but it was not clear how this was to be taken forward.
  • Patients were supported to die in their preferred place of care where this had been identified. However, not all patients had a record of their preferred place of care at the end of life, particularly those who did not receive support from the specialist palliative care team.
  • Staff expressed concerns about potential duplication of service in relation to services from other providers across the county. This view was supported by a May 2018 county wide end of life care service review where it was identified there was a potential for duplication or gaps in service because of a lack of governance and strategy across the service.
  • The maintenance and use of equipment and the design and use of facilities and premises did not always keep patients safe. Syringe drivers in community hospitals were not always maintained in line with the trust policy and unsafe manual handling techniques were observed in the body store at Ross community hospital.
  • The trust did not provide assurance that standards of hygiene and cleanliness were maintained within the body stores at Ross and Bromyard Community Hospitals as cleaning logs and records were not always maintained.

However:

  • Patients received specific advice about their medicines in line with current national guidance and evidence, including the use of anticipatory medicines and medicines for use in a palliative crisis.
  • Training attendance for the specialist palliative care team was above the trust target in eight out of nine mandatory training modules for the team.
  • Safeguarding training attendance for the specialist palliative care nurses was above trust target. Community nursing staff demonstrated a good understanding of safeguarding processes when caring for patients in their own homes.
  • Patients’ physical, mental health and social needs were holistically assessed, and their care, treatment and support delivered in line with legislation, standards and evidence-based guidance.
  • Information about the outcomes of patient’s care and treatment was routinely collected and monitored by the specialist palliative care team. This information was used to raise awareness amongst staff teams.
  • Staff had access to one-to-one meetings, appraisals, clinical supervisions and mentoring in order to delivery effective care and treatment. The specialist palliative care team exceeded the trust target for the achievement of 90% of staff appraisals in the last year.
  • Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved through the use of regular multi-disciplinary meetings.
  • The specialist palliative care service was available seven days a week in the community. This meant that access to services was maintained over the weekend and bank holidays and that continuity of care was available.
  • Staff were committed to ensuring the patient experience at the end of life was as positive as possible. There was positive feedback from patients and their relatives and we were told of situations where staff had gone beyond what was expected of them in their support of patients at the end of life.
  • Patients were supported to be actively involved in making decisions about their care. For example, choices and wishes about end of life care were recorded as part of the multidisciplinary care record in use at the end of life.
  • Patients privacy and dignity were respected. Results from a bereaved relative’s survey showed 100% satisfaction with how dignity was respected by the specialist palliative care team.
  • Specialist palliative care staff worked across all community services to coordinate patient’s involvement with families and carers at the end of life.
  • Where identified, patients who may be approaching the end of their life were supported to make informed choices about their care. There was evidence of decisions about care recorded in patient records that included the wishes or family members as well as the patient.
  • Patients had timely access to the specialist palliative care team. The majority of patients referred to the team were contacted within three days.
  • There was a clear vision to deliver quality and sustainable end of life care across all community services we visited.
  • The culture of end of life care services were centred on the needs and experience of patients who use services.
  • Patients views and experiences were gathered and acted on to shape and improve the specialist palliative care service and culture
  • There was evidence of service improvement and innovation. For example, the specialist palliative care team were leading on the implementation of a quality improvement programme to support care homes in the community.

5, 6, 7, 8, 11, 17, 18 July 2016

During a routine inspection

Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of 186,000 people in Herefordshire and a population of more than 40,000 people in mid-Powys, Wales. The trust also provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham. During this inspection we only inspected the services provided by Hereford Hospital. We did not inspect community services provided by the trust. Therefore, the overall rating for community services remains as requires improvement, as per the September 2015 inspection.

There are approximately 236 beds of which 208 are general and acute, 22 maternity and six critical care beds within Hereford Hospital. The trust employs 2,601 whole time equivalent staff as of June 2016..

We carried out this inspection as part of our comprehensive programme of re-visiting trusts which are in special measures. We undertook an announced inspection from 5 to 8 July 2016 and unannounced inspections on 11, 17 and 18 July 2016.

Overall, we rated Hereford Hospital as requires improvement with three of the five questions we ask with safe, effective and well led being judged as requiring improvement. We rated Hereford Hospital as inadequate for being responsive as patients were unable to access all services in a timely way for initial assessments, diagnoses and/or treatment.

We rated caring as good. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.

Our key findings were as follows:

Safe

  • There was a high vacancy rate which meant an increased use of agency and bank staff. The safer nurse staffing levels were planned in line with the national recommendations. The average trust fill rate for registered nurses remained below 95%, ranging from 74.5% on Wye ward to 109.4% on Monnow ward for June 2016. The trust strategy was to cover unfilled registered nurse shifts with a health care assistant where appropriate, to help mitigate staffing level risk. For June 2016 the hospital health care assistant fill rate was 116% for day shifts and 122% for night shifts. We found actual staffing levels met planned staffing levels on most wards during our inspection. We found no incidents relating to staff shortages directly affecting patient care at ward level.
  • Mandatory and statutory training compliance for June 2016 was at 86% which although had improved from 78% in July 2015, did not meet the trust target of 90%.
  • Patients’ weight was not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of the medicine.
  • In maternity, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby.
  • Staff were aware of their responsibilities regarding safeguarding procedures.
  • Staff understood their responsibility to report concerns, to record safety incidents and near misses. Staff received feedback on all incidents.
  • Staff had an awareness of the duty of candour process, however just prior to the inspection the trust had identified that it was not following all the requirements of the regulation in that it was not confirming their discussions with patients in writing and had put actions in place to address this.
  • Ward and clinical areas were visibly clean and staff were observed following infection control procedures.
  • There were systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.

Effective

  • The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated more patients were dying than would be expected. This had been reported to the trust board and an action plan was in place to understand and improve results.
  • The caesarean section rate was significantly higher (worse) than the national average and the deteriorating rate was not recorded on the risk register.
  • Most care was delivered in line with legislation, standards and evidence-based guidance. However, some trust guidelines needed updating.
  • The service had a series of care bundles in place, based on the appropriate guidance for the assessment and treatment of a series of medical conditions. However, there was no hip fracture pathway within the hospital although we were told that this was being drafted.
  • The trust had processes in place to monitor some patient outcomes and report findings through national and local audits and to the trust board. Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.
  • Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Caring

  • Staff were observed being polite and respectful during all contacts with patients and relatives. Staff protected patients’ privacy and dignity.
  • Patients felt involved in planning their care.

Responsive

  • The emergency department consistently failed to meet standards in terms of the amount of time patients spent in the department and waited for treatment.
  • Bed occupancy was consistently worse than the national average.
  • Patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses and/or treatment. The trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.
  • The trust did not consistently meet all cancer targets for referral to treatment times.
  • Overall referral to treatment indicators within 18 weeks for admitted surgery patients was worse than the England average.
  • The percentage of patients that had cancelled operations was worse than the England average.
  • Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on the intensive care unit each month.
  • The trust did not have an electronic system in place to identify patients living with dementia or those that had a learning disability.
  • Staff adapted care and treatment to meet patient’s individual needs.
  • We saw examples of services planning and delivering care to meet the needs of patients.
  • Systems and processes were in place to provide advice to patients and relatives on how to make a complaint.

Well-led

  • The trust had governance oversight of incident reporting and management. The board assurance framework and corporate risk register identified most of the keys risks.
  • The executive team could demonstrate good understanding of the risks, issues and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.
  • The trust implemented a new organisational structure in June 2016, with three service units reduced to two divisions, medical and surgical. Although staff felt the reconfiguration was positive and provided more support we were unable to assess the sustainability and effectiveness of the restructure as this had not yet been fully embedded into the trust.
  • The trust had a vision, their mission and their values. However, these were not fully embedded or understood by staff.
  • There was no equality and diversity strategy.
  • Following the trust being placed into special measures in October 2014, a comprehensive quality improvement plan was developed, which included a number of projects and actions. We saw that the action plans were reviewed regularly, with monitoring of compliance against targets and details of completed actions.
  • There was a sense of pride amongst staff towards working in the hospital and they felt respected and valued.
  • We were assured that appropriate steps had been taken to manage the ‘Fit and Proper persons’ legislation implementation.

We saw several areas of outstanding practice including:

  • Services for children and young people were supported by two play workers (one was on maternity leave at the time of inspection). The play workers regularly made arrangements for long term patients to have days out to different places, including soft play areas or bowling. An activity was arranged most months and the play workers sourced the activities from local businesses who donated their good and/ or services. This meant that patients with long term conditions could meet peers who also regularly visited the hospital. Patients found this valuable and liked the opportunity to meet patients who had shared experiences.
  • There was a children’s and young people’s ambassador group which was made up of patients who used or had used the service. We spoke with some members of the ambassador group who told us that they were involved in the service redesign when developments took place and improving the service for other patients.
  • The respiratory consultant lead for non invasive ventilation had developed a pathway bundle, which was used for all patients requiring ventilator support. The pathway development was based on a five-year audit of all patients using the service and the identification that increased hospital admissions increased patient mortality. The information gathered directed the service to provide an increased level of care within the patient’s own home. Patients were provided with pre-set ventilators and were monitored remotely. Information was downloaded daily and information and advice feedback to patients by the medical team. This allowed treatments to be altered according to clinical needs. The development had achieved first prize in the trust quality improvement project 2016.
  • The newly introduced clinic for patients with epilepsy had enlisted the support of a patient with epilepsy; their views had helped the clinic develop so that the needs of patients were met.
  • Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and twiddle mittens provided as patient activities. The unit provided regular activities for patients, which included monthly tea parties and games.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the emergency department.
  • The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment.
  • The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps.
  • The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine.
  • The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously.
  • The trust must ensure all medicines are stored in accordance with trust polices and national guidance, particularly in outpatients.
  • The trust must ensure that all patients receive effective management of pain and there are enough medicines on wards to do this.
  • The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.
  • The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.
  • The trust must ensure staff receive appraisals which meet the trust target.
  • The trust must ensure that patients are able to access surgery, gynaecology and outpatient services in a timely way for initial assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets.
  • The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the waiting list.
  • The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded accurately.
  • The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children and young people’s services.
  • The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy.

The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

Please refer to the location report for details of areas where the trust SHOULD make improvements.

The trust was placed into special measures in October 2014. Due to the improvements seen at this inspection, I have recommended to NHS Improvement that the special measures are lifted.

Professor Sir Mike Richards

Chief Inspector of Hospitals

22 to 25 September 2015

During a routine inspection

Wye Valley NHS Trust provides hospital care and community services to a population of slightly more than 180,000 people in Herefordshire. The trust also provides urgent and elective care to a population of more than 40,000 people in mid-Powys, Wales.

The trust’s catchment area is characterised by its rural nature and remoteness, with more than 80% of service users living five miles or more from Hereford city or a market town. The trust has 387 beds and provides a full range of district general hospital services.

We inspected the trust in June 2014 and gave an overall rating of ‘Inadequate’, with particular concerns about the provision of services in both urgent and emergency services and medical care services. The inspection led to the trust being placed in special measures by the Trust Development Authority in October 2014. The trust developed a patient care improvement plan in order to implement improvements. An improvement director was appointed by the Trust Development Authority and commenced work in February 2015 to assist the trust to progress.

We undertook an announced inspection of Hereford Hospital, Bromyard, Leominster and Ross Community Hospitals between 22 and 24 September 2015. We undertook unannounced inspections on 25 September 2015 at Leominster Community Hospital and 1 October 2015 at Hereford Hospital.

We held focus groups with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, allied health professional, domestic staff and porters. We also spoke with staff individually.

There were some areas of improvement from the previous inspection particularly within community services and urgent and emergency service. However, there were areas where significant improvement was required.

Overall, we rated Wye Valley NHS Trust as inadequate, with two of the five key questions which we always rate being inadequate (safe and responsive). Improvements were needed to ensure that services were safe and responsive to patient’s needs. We found that effectiveness and well led required improvement.

Five of the eight core services at Hereford Hospital were rated inadequate for safety.

The outpatient and diagnostic services at Hereford Hospital were rated overall as inadequate. All other services at Hereford Hospital were rated as requires improvement.

All community services were rated as good, with the exception of community inpatient services and community end of life care which were rated as requires improvement.

Overall we have judged the services at the trust as good for caring. Patients were treated with dignity and respect and were provided with appropriate emotional support. We found caring in community adult services to be outstanding.

Our key findings were as follows:

  • Staff were kind and caring and treated people with dignity and respect.
  • Overall the hospital was clean, hygienic and well maintained.
  • Equipment was not always appropriately checked and maintained.
  • Recruitment was a significant risk for the trust.
  • The trust had high vacancy levels across both nursing and medical staff. With some areas having vacancy levels in excess of 40% for nursing staff at the time of the inspection.
  • Temporary staff usage was high and temporary staff did not always receive an effective induction.
  • Staff did not always have the appropriate training.
  • A recruitment programme was ongoing and changes had been made to speed up the recruitment process. Oversees recruitment had taken place.
  • Patient’s pain was well managed and women in labour received a choice of pain relief. Patients at the end of life were given adequate pain relief and anticipatory prescribing was used to manage symptoms.
  • Monitoring by the Care Quality Commission had identified mortality was above the expected range of 100 with a value of 114. The trust were implemented a series of actions to address this concern.
  • The trust were not consistently meeting the national targets set regarding patients access to treatment and there was lack of oversight of the risk this presented to patients.
  • The trust were not meeting the standard for patients admitted, referred or discharged from the emergency department within four hours.
  • The trust did not have effective governance oversight of incident reporting and management, including categorisation of risk and harm. Incident management was not effective as to allow for the timely mitigation of the risks relating to the health, safety and welfare of service users.
  • There was a lack of knowledge amongst trust staff with whom we spoke about when to make safeguarding referrals.
  • Staff generally felt they were well supported at their ward or department level.
  • Visibility of the executive directors had improved since the last inspection.

We saw several areas of outstanding practice including:

  • The trust had established a young people’s ambassador group. This was run by a group of patients who had used the service or continued to use the service. The group met regularly and were consulted on changes on changes and developments, for example they had recently introduced a ‘Saturday club’ and had been involved in the ED Patient-Led Assessment of the Care Environment audit (PLACE) aiding the redesign of the children’s waiting are; and had been involved in interviewing new staff in community services for children and young people. We spoke with some representatives from the group who were very passionate about their role and welcomed the opportunity to make a difference.
  • Compassionate care and emotional support provided by community adult service teams was excellent. Staff had a clear focus for providing best possible care and improving the well-being of patients they saw.
  • Community services for children and young people had submitted a proposal for a group project incorporating local health visiting teams, children’s centres, the local community and various members of the multi-agency team. The aims of the project were to: provide support and information to families on how to achieve healthy lifestyles; promote and support and encourage sensible weight management; enhance families ability to cook health nutritious meals; increase families social networks and therefore their social capital, leading to increased self-esteem and self-confidence; enhance links within the community by incorporating volunteers from within the community to help within practicalities of running groups on a regular basis; encourage links to other services within the community that promote lifestyle change, such as local gyms and swimming pool.
  • Health visitors in Leominster supported children in need at Christmas with a Christmas hampers project by utilising local community charities and food bank services to donate food hampers for families in need.
  • Health visitors at Ross Community Hospital had an allotment project to improve community engagement and encourage healthy eating. HVS had worked with a local charity to access allotments, for use by local communities to grow their own produce and share with families who had food and nutritional needs.
  • A member of the Leominster SNS team had won a prize from a national professional journal for producing a domestic abuse peer support programme.
  • The development of ‘Fresh Eyes Peer Review’, for complaints, which is an excellent example of a non-threatening, transparent, open and supportive initiative in organisational learning.
  • The education team had effective plans in place and appropriate clinical direction. The team had been well embedded for some years and that the team was a beacon of good practice within the trust.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • The trust must ensure safeguarding referrals are made as appropriate.
  • The trust must ensure all staff have the appropriate level of safeguarding training.
  • The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.
  • The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.
  • The trust must ensure staff receive and appraisal to meet the appraisal target of 90% compliance.
  • The trust must ensure there are enough suitably qualified staff on duty within all services, in accordance with the agreed numbers set by the trust and taking into account national recommendations.
  • The trust must ensure there are the appropriate number of qualified paediatric staff in the ED to meet standards set by the Royal College of Paediatrics and Child Health 2012 or the Royal College of Nursing.
  • The trust must ensure consultant cover meets with the Royal College of Emergency Medicine’s (RCEMs) emergency medicine consultants workforce recommendations to provide consultant presence in the ED 16 hours a day, 7 days a week as a minimum.
  • The trust must ensure processes in place are adhered to for the induction of all agency staff.
  • The trust must ensure ligature points are identified and associated risks are mitigated to protect patients from harm.
  • The trust must ensure risk registers reflect the risks within the trust.
  • The trust must ensure all incidents are reported, including those associated with medicines.
  • The trust must ensure effective and timely governance oversight of incident reporting management, including categorisation of risk and harm, particularly in maternity services.
  • The trust must review the governance structure for all services at the hospital to have systems in place to report, monitor and investigate incidents and to share learning from incidents.
  • The trust must ensure that all trust policies and standard operating procedures are up to date and that they are consistently followed by staff.
  • The trust must ensure all medicines are prescribed and stored in accordance with trust procedures.
  • The trust must ensure patient records are stored appropriately to protect confidential data.
  • The trust must ensure patient records are accurate, complete and fit for purpose, including Do Not Attempt Cardio-Pulmonary Resuscitation forms and prescription charts.
  • The trust must ensure risk assessments are completed in a timely manner and used effectively to prevent avoidable harm, such as the development of pressure ulcers within ED and pain assessments for children.
  • The trust must ensure that mortality reviews are effective with the impact of reducing the overall Summary Hospital-level Mortality Indicator (SHMI) for the service.
  • The trust must ensure there are robust systems are in place to collect, monitor and meet national referral to treatment times within surgery and outpatient services.
  • The trust must ensure there are systems in place to monitor, manage and mitigate the risk to patients on surgical and outpatient waiting lists.
  • The trust must ensure staff check the “site” of the operation to ensure this is appropriately marked, prior to the operation; and ensure that the “site” of the operation is documented on the 5 Steps to Safer Surgery checklist.
  • The trust must ensure all incidents of pressure damage are fully investigated, particularly within ITU.
  • The trust must ensure there is a policy available to ensure safe and consistent practice for parents to administer medicines to their children.
  • The trust must ensure there is a system in place to recognise, assess and manage risks associated with the temperature of mortuary fridges.
  • The trust must ensure clinicians have access to all essential patient information, such as patients’ medical notes, to make informed judgements on the planned care and treatment of patients.
  • The trust must ensure outpatients patients are followed up within the time period recommended by clinicians.
  • The trust must ensure that the categorisation of incidents is completed accurately and full investigations are carried out as appropriate, including the identification of themes to ensure relevant actions are implemented.
  • The trust must ensure that governance systems in place are effective. This includes ensuring practices are consistent, in line with hospital policies, and documents are approved through the clinical governance structure.

Following the inspection we issued Hereford Hospital with a warning notice under section 29a of the Health and Social Care Act 2008. On the basis of this inspection, we are recommending the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

22, 23 and 24 September 2015

During an inspection of Community end of life care

Overall rating for this core service Requires Improvement l

The community end of life service were rated overall as requires improvement. Improvements were required in relation to the assessment of patients’ mental capacity to make decisions before decisions were made about care that was in their best interests. The specialist palliative care team (SPCT) worked as part of a multidisciplinary team approach between hospital and community based services, with specific team members dedicated to providing the community element of specialist care. Their role was to assess, support, deliver, monitor and evaluate end of life and palliative care provided by the service. Services provided safe, coordinated care and we saw that staff were focused on continual learning and service development. Equipment used for patients at the end of life was easily accessible in the community and staff told us they felt they had the resources to deliver quality care.

The organisation did not have the all the processes and information to manage current and future performance. The trust did collect some information on the percentage of patients who died in their preferred location. However, the trust did not collect information on the percentage of patients who achieved discharge to their preferred place within 24 hours. Without this information, we were unable to monitor if the trust was able to honour patients’ wishes. Without collecting this information, the trust was unable to assess if they needed to improve on this.

End of life care within the community was influenced by national guidance such as the Gold Standards Framework and we saw that good multidisciplinary working was in operation with the needs of the patient central to all care activities. Patients and relatives we spoke with told us the care they received was delivered with compassion and that they were respected and treated with dignity. The community provided a seven day specialist palliative care advice service and we saw that the needs of the local population were considered when reviewing the service provided. Improvements had been made to the assessment and care planning of patients at the end of life with the development of a multidisciplinary care record for the last days of life. We also saw that the trust had taken action to replace the syringe drivers in line with national recommendations. The SPCT attended mandatory training although there were some areas where compliance was as low as 50%.

We saw evidence of a clear vision developed for end of life care and there was proactive leadership at SPCT and community service levels. Trust board representation for end of life care had been identified although not yet developed or embedded which meant we did not see evidence of proactive board level involvement in terms of the development of the end of life care strategy.

22, 23 and 24 September 2015

During an inspection of Community health inpatient services

Overall rating for this core service Requires Improvement l

Overall, we found that:

There was limited evidence all relevant investigations and risk factors were considered when reviewing incidents. Safeguarding training data provided by the trust demonstrated that 52% of community inpatient staff had received appropriate training. Systems, processes and standard operating procedures were not always reliable or appropriate to keep patients safe. Checks on fridge and room temperatures where medicines were stored varied, and checks on medication that had stricter legal requirements were inconsistent. Nursing audits identified community inpatient staff did not always complete relevant assessments appropriately. Where staff had identified risks through an assessment, they had not always put in place relevant management plans. The trust was actively trying to ensure there were sufficient numbers of staff in the community hospitals. However, we were not confident appropriate action was taken to ensure an appropriate skill mix maintained the needs of patients and keep them safe. Staff did not fully recognise, assess or manage the risks associated with anticipated events and emergencies.

Care and treatment did not always reflect current evidence-based guidance, standards and best practice. Care assessments did not consider the full range of patients’ needs, in particular pain management. There were gaps in management and support arrangements for staff, such as appraisal, supervision and professional development. There were inconsistencies in staff maintaining competencies and developing their roles through additional training. There was no assurance regarding the revalidation and appraisal for the GPs providing medical cover at the community hospitals. Completed records were inconsistent in relation to when a mental capacity assessment was completed.

Patients and relatives informed us staff did not always involve them in their care or that of their loved one, particularly discharge planning.

When planning services, local population needs were not always fully understood or taken into account. Access to the therapy services was not always available in line with the patient’s individual needs. Records demonstrated there was limited learning across the sites from complaints and concerns.

There was no strategy for the community inpatient service to support the vision of the trust. The arrangements for governance and performance management did not always operate effectively. There were inconsistent practices in place across the community hospitals and some documents in use were not ratified through the governance process. Not all leaders took part in all aspects of service development. There was mixed staff satisfaction. Staff did not always feel actively engaged and that they were part of one trust. The approach to service delivery and improvement was reactive and focused on short-term issues. Staff did not always identify improvements to ensure the trust sustained safe, quality care.

Staff were knowledgeable about incident reporting and the new duty of candour regulation (being open and honest with patients and relatives, as appropriate).

Relevant staff were included in the assessment, planning and delivering of patient care and treatment and GPs were able to access patient results from the trust’s electronic reporting system. Staff had a good awareness of the Mental Capacity Act 2005 (MCA) assessments and Deprivation of Liberty Safeguards (DoLS).

Patients and relatives were positive about the way staff treated them. Staff treated patients with dignity, respect and kindness. Staff helped patients and those close to them to cope emotionally with their care and treatment. Patients were supported and encouraged to manage their own health and care when they could, to maintain their independence.

Staff were aware of specific needs individual patients had and were able to put in place appropriate arrangements, where possible. Staff were knowledgeable about the complaints process and what action they would take.

Risks and issues described by staff corresponded to those reported and were understood by leaders. Leaders were clear of their roles and accountabilities.

22, 23 and 24 September 2015

During an inspection of Community health services for adults

Overall rating for this core service Good l

Overall we found adult community services to be good.

Staff across the service understood the importance of reporting incidents and did so appropriately. Lessons learnt from incidents were shared amongst teams which we saw evidence of. Whilst there were vacancies across the majority of teams, staff felt the current workload was manageable and teams often provided support to each other when demand increased. Specialist services such as multiple sclerosis had insufficient capacity to meet demand. The specialist nurse worked alone and if sick or on leave there was no provision to support the service.

Training levels on subjects such as manual handling and safeguarding varied across community services meaning the knowledge level of all staff was not consistent.

Multi-disciplinary team working was apparent with services using referral pathways as required and there were good links with local GP practices.

Appraisals and peer to peer learning provided staff with time to develop and share knowledge. Staff felt well supported in continuing professional development and were provided with clinical and caseload supervision at regular intervals.

We saw compassionate and considerate care throughout community services. Staff often went above and beyond the requirements of their role to ensure patients received high quality care, including taking information and advice leaflets to patients whilst on their journey home to ensure they felt supported. Staff were extremely passionate about their role in improving patient conditions not only clinically but also emotionally. Well-being was a strong focus in all contacts with patient and consistent positive feedback was given about services provided.

Culture within the community teams was positive and staff felt well supported by their local managers and other colleagues. Teams worked well together and staff engagement was regularly sought. However, we found staff were not aware of a strategy within community services and often felt that changes were rushed which made effective implementation difficult. Staff within community services felt that there was a strong focus on improving acute care and there was minimal recognition for their work at an organisational level.

23 September 2015

During an inspection of Community dental services

Overall rating for this core service Good l

We found dental services provided safe and effective care. Patients’ were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.

Dental services were effective and focussed on the needs of patients and their oral health care. We found the overall care provided at the service to be good. We observed good examples of effective collaborative working practices within the service. The service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.

Effective multidisciplinary team working ensured patients were provided with care that met their needs and at the right time. This was achieved by thorough effective management of resources.

At the time of inspection we saw no evidence to indicate that the service collected referral to treatment times for urgent and routine referrals, only for patients requiring general anaesthetic. This meant that the services stablished systems and processes did not operate effectively to monitor all the dental services waiting time data. Waiting times for patients requiring general anaesthetic ranged between six and 14 weeks. This met the national 18 week referral to treatment target.

The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said that they generally felt well supported and that they could raise any concerns.

22, 23 and 24 September 2015

During an inspection of Community health services for children, young people and families

Overall rating for this core service Good l

Community children and young people’s safety performance was monitored by dashboards and governance processes. When something went wrong there was a process in place to review or investigate incidents involving all staff, children, young people and their families. Lessons were learned and communicated widely to support improvement in all children’s and young people’s services, as well as services that were directly affected. There were clearly defined and embedded systems and processes to keep children and young people safe and safeguarded from abuse. Staff received up-to-date training in safeguarding to an appropriate level. There was active and appropriate engagement in local safeguarding procedures and effective working with other relevant organisations. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Monitoring and review processes and meetings enabled staff to understand risks and gave a clear and accurate picture of safety.

Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe at all times. Any staff shortages were responded to quickly and adequately to ensure staff could manage risks to children and young people who used services.

Risks to children and young people were assessed, monitored and managed on a day-to-day basis. Staff recognised and responded appropriately to changes in risks to children and young people who use services. Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.

Children and young people had good outcomes because they received effective care and treatment that met their needs. Children and young people’s care and treatment was planned and delivered in line with current evidence-based guidance, best practice and legislation, including the Healthy Child Programme (2009) (HCP). This was monitored to ensure consistency of practice.

There was participation in relevant local audits and other monitoring activities such as service reviews and service accreditation. Accurate and up-to-date information about effectiveness was shared internally and externally and was understood by staff, and used to improve care and treatment and children and young people’s outcomes.

Children were cared for by a multidisciplinary team of dedicated and skilled staff. Staff felt supported and had access to training. Wye Valley NHS Trust was an early implementer site (EIS) for the ‘health visitor implementation plan 2011-2015’.

Children and young people and their parent were supported, treated with dignity and respect, and were involved as partners in their care. Feedback from children, young people and families was positive. Children and young people and families felt supported and said staff cared about them. Children and young people were involved and encouraged in making decisions about their care. They were communicated with and received information in a way they could understand. Staff responded compassionately when children and young people needed help and supported them to meet their basic personal needs. Children and young people’s privacy and confidentiality was respected at all times.

Children and young people’s services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services provided. Building community capacity was a key aspect of the community early implementation service (EIS) plan, this emphasised delivering services in a range of settings to maximise the number of people that had access to a range of services.

The integrated family health services (IFHS) model bridged health and social care. The aim of the service model was to improve children and young people’s outcomes and experience through bringing existing community services from health and social care into a more combined way of working. Children’s and young people’s care and treatment was co-ordinated with other services and other providers.

The trust was working with the clinical commissioning group (CCG) and local authority to ensure children had new offers for respite care, prior to closure of 1 Ledbury Road respite unit in March 2016.

Complaints handling policies and procedures were in place. All complaints to the service were recorded. Information on the trust’s complaints policy and procedures was available on the trust’s internet website.

The leadership, governance and culture of community children and young people’s services promoted the delivery of child-centred care. The trust had a clear statement of vision and values that had been developed through a structured planning process with regular engagement from staff. The IFHS community children and young people’s service was undergoing a significant reorganisation of services. We found that some staff were unclear about the long term strategy for health visiting and school nursing services. The trust board and other levels of governance within community children and families services functioned effectively and interacted with other services appropriately. Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, were clearly set out and understood.

3, 4, 5 and 19 June 2014

During a routine inspection

Wye Valley NHS Trust was established on 1 April 2011. The trust provides community services and hospital care (acute and community) to the population of Herefordshire. It also provides urgent and elective care to people in Powys Mid Wales. There are 18 locations registered with the Care Quality Commission (CQC); we visited Hereford County Hospital, Hillside Centre and Leominster, Ross on Wye and Bromyard community hospitals as part of this inspection.

We carried out a comprehensive inspection because Wye Valley NHS Trust had been flagged as high risk on CQC’s Intelligent Monitoring system (which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations). The announced inspections took place on 3, 4, 5, June with an unannounced inspection on 19 June 2014.

Overall, we found that services at Wye Valley NHS Trust were inadequate, with particular concerns about services in A&E and medical care. We rated it as ‘good’ for providing services that were caring, but A&E services were falling short of the level of care that would be expected. Improvement is required for the trust to provide effective care, and it was rated as inadequate for safety, for being responsive to patient needs and for being well-led.

Our key findings were as follows:

  • Across the trust the majority of staff in both acute and community teams were caring and compassionate. But in A&E we found that patients’ personal needs were not always met and they had limited access to fluids and food.
  • Privacy and dignity was maintained in most areas, but there were areas, such as in A&E and outpatients, where a lack of space or adequate sound proofing was preventing privacy at all times.
  • Overall, the trust was clean and well maintained across both acute and community locations.
  • Incident reporting was inconsistent. Not all staff were confident to report incidents. Some groups of staff did not have access to the electronic reporting system. Some explained that they would tell the nurse in charge and it would be up to them to decide whether to report it or not. There was a lack of feedback following incidents. This was seen across many service areas.
  • There were examples of poor systems for the management of medicines. These were not consistently in line with the trust’s policy, with examples of poor storage and administration. 
  • Forms for “do not attempt cardiopulmonary resuscitation” (DNA CPR) were not completed in line with the trust’s policy.
  • The trust had a higher than expected mortality rate for the demography of the patients admitted as measured by the Hospital Standardised Mortality Ratio.
  • The trust needed to confirm the future of stroke services. There was no appropriate access to specialist staff, inadequate escalation to stroke consultants and a low number of people receiving thrombolysis therapy.
  • Staff needed access to training to ensure that they have the correct competencies, skills and expertise to effectively care for and treat patients.
  • Mandatory training for staff was not up to date, with particular shortfalls in safeguarding of vulnerable adults and children and in the Mental Capacity Act. The trust recognised this and was taking action to address.
  • There were some examples of patients not having sufficient access to adequate nutrition and hydration.
  • There were shortfalls across the trust in medical, nursing and midwifery staffing, which affected day-to-day care. It was also preventing the development of seven-day services in some areas, for example, in endoscopy and stroke care.
  • There were significant issues with the flow of patients into, through and out of the trust, with high bed occupancy rates, sometimes rising to over 100%. The trust was failing to meet the four-hour target for patients attending A&E to be admitted, discharged or transferred. There were instances when patients remained on a trolley in A&E for over 12 hours. The trust was not able to accommodate medical patients in medical beds, and was having to use beds on the surgical wards, the surgical day unit, the clinical assessment unit and the discharge lounge. This resulted in delays in reviewing patients, elective operations being cancelled and difficulty finding beds for patients who needed to be admitted from outpatients. Due to the capacity issues, additional beds had been opened in one of the community hospitals, but it was difficult to access additional staff.
  • Equipment was not always accessible or appropriately stored.
  • Staff in children and young people’s services in both the acute and community settings felt they were not integrated with other services in the trust.
  • There were areas throughout the trust where risks were not escalated and therefore not effectively acted on. There was poor correlation between the risks discussed by staff and the trust’s risk register.
  • Audits were being undertaken, but in some areas there was a lack of evaluation of the effectiveness of care (outpatients and end of life care in the community).
  • In some areas nursing staff were undertaking responsibilities beyond their grade and level of experience.
  • Clinical supervision was not well developed.
  • Staff in community teams felt vulnerable when working on-call, particularly at night, and sometimes having long distances to travel with poor mobile signals.

We saw several areas of outstanding practice including:

  • Dedicated and committed staff going the extra mile for their patients.
  • Virtual wards, hospital at home and complex discharge coordinators, which had been established to prevent patients from needing to come into hospital and to promote timely and effective discharges.
  • There were excellent preoperative assessments, which included a public health element.
  • Community services for children were recognised to be good in all five key questions that we assessed.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that all environments support the privacy and dignity of patients.
  • Ensure that all patients have access and support if required to appropriate foods and fluids.
  • Ensure that all staff have access to report incidents, feel confident to do so, receive feedback that lessons are learned and where appropriate, that learning is disseminated across the trust.
  • Ensure that reviews of patients are undertaken in a timely manner and that patients do not get lost in the system.
  • Ensure that action is taken to improve the flow of patients into, through and from the trust.
  • Ensure that improvements are made to discharge planning and arrangements, so that people are able to leave hospital when they are ready. Work must continue with partners to ensure that discharge arrangements have patients at the heart of the process.
  • Ensure that risks are recorded, escalated and acted on.
  • Improve end of life care in both the hospital and the community.
  • Ensure that medicines are managed in line with the trust’s medication policy.
  • Ensure that forms for recording “do not attempt cardiopulmonary resuscitation” are completed in line with trust policy.
  • Continue to improve mortality rates.
  • Confirm the future of stroke services, ensuring that there is appropriate access to care both now and in the future. 
  • Ensure that staff receive both mandatory training and training to ensure they have the correct competencies, skills and expertise to effectively care for patients. 
  • Ensure that staff are undertaking responsibilities within their grade and level of experience.
  • Ensure that the effectiveness of care is audited and findings acted upon.
  • Review the support for staff on call at night who may be travelling and unable to access help and advice if required.
  • Develop clinical supervision.
  • Ensure that equipment is available and appropriately maintained and stored.

Please refer to the separate reports for locations and community services for details of areas where the trust SHOULD make improvements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.